Low-income, minority teenagers have disproportionately high rates of asthma morbidity, including excess risk of emergency department visits, hospitalizations, and death from asthma. Despite well established guidelines, under-treatment for asthma is common, particularly for poor urban teens. Our prior work has demonstrated that school-based directly observed therapy (DOT) of preventive asthma medications can improve outcomes for young, urban children with persistent asthma. We have also found that school-based telemedicine can effectively facilitate assessments by primary care providers (PCPs) for preventive medication prescriptions for DOT and for follow-up care. We recently conducted a study for teens with persistent asthma which included a trial of DOT of preventive medications at school paired with motivational interviewing (MI) counseling to promote independent adherence. While this program successfully improved medication adherence, it had a limited effect on asthma symptoms, and in particular many of the teens with moderate to severe persistent asthma at baseline continued to experience poor control despite the intervention. This was at least in part because for many of these teens, the medications initially prescribed for DOT were not optimally adjusted by PCPs and their asthma was undertreated. We realize that this program may be insufficient for these teens (> of the overall sample), since access to recommended specialist consultation for medication step-up or management of co-morbidities was not included. Further, while education and self-management support are critical for this age group, the MI counseling in this program required resources for several in-person visits. We now aim to test a novel, developmentally appropriate and scalable model of care to ensure optimal guideline- based treatment for urban teens with difficult to control asthma. The Telemedicine Enhanced Asthma Management-Uniting Providers for Teens (TEAM-UP Teens) program includes 3 core components: 1) An optimized asthma management plan developed at the start of the school year via a real-time, synchronous school-based telemedicine visit that directly connects the teen to an asthma specialist, 2) School-based DOT to implement the medication plan and allow for teens to experience the benefits of consistent therapy, 3) Follow-up telehealth visits with a nurse asthma educator to facilitate ongoing care and provide developmentally appropriate self-management support. In response to PA-18-722; Improving Patient Adherence to Treatment and Prevention Regimens, we propose a full-scale randomized trial of TEAM-UP for Teens vs an enhanced care (EC) control group (n=360, 12-16yrs). We will capitalize on the existing community infrastructure by implementing both telemedicine visits and DOT in schools. We will assess the effectiveness of TEAM-UP for Teens in reducing morbidity and improving guideline-based care (primary outcome: symptom-free days at 3, 6, 9, and 12 months) versus EC. At the study's completion, the program will be better defined as a sustainable means to improve care and reduce morbidity for high risk teens with moderate to severe persistent asthma.